COUNCIL OF COMMUNITY PROGRAMS

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1 MENTAL HEALTH DEVELOPMENTAL DISABILITIES & SUBSTANCE ABUSE NORTH CAROLINA COUNCIL OF COMMUNITY PROGRAMS AREA DIRECTOR S FORUM Notes April 8, 2011 Alamance-Caswell Durham Guilford O-P-C Southeastern Center Beacon Center ECBH Johnston Pathways Southeastern Regional CenterPoint Eastpointe Mental Health PBH Wake Ramon Partners Crossroads Five County Mecklenburg n Sandhills Western Highlands Cumberland Onslow-Carteret Smoky Mountain Staff: Yvonne Copeland, Ann Rodriguez Chairperson: Betty Taylor, Centerpoint DHHS: Mike Watson, Jim Jarrard, Kelly Crosbie, Beverly Bell, Steve Jordan, Yvonne French, Walt Caison, Flo Stein Welcome & Roll Call Betty Taylor started the meeting at 9:35 with roll call. Several LMEs joined via conference call. Council Discussion Waiver RFA: Discussion of various aspects of the recently disseminated RFA inviting LMEs to apply for waiver status. The public requirement reflects the combined efforts of key legislators and DHHS. Yvonne was recognized for work on behalf of LMEs. LMEs agreed that it is imperative for all to be on the same page with this effort, and that it is important to demonstrate this to the legislature. We need to push for success and for the process to be a reasonable one. Betty asked for comments, questions, and issues: There are inconsistencies between legislative language and Secretary s presentation regarding the start date (1/1/13 vs. 7/1/13). This needs to be clarified. DHHS cannot answer questions outside of the formal Q&A process due to rules for RFAs. Hopefully this question will be triaged and answered quickly. When rules are in conflict with RFA, which do we go with? Another question to be sent to DHHS for formal response. County commissioners need to get thru their processes. Changes will feel radical at home. Trying to get declaration date moved to 7/1/11 to allow for reasonable local processes to complete that. Legislature ok with date change. DHHS needs to agree, but has to do this thru the Q&A process. Confusion about population number changes. 300,000 to 500,000 doesn t make sense. Just say 500,000 by date certain. Division sent document to CFAC on statewide waiver expansion dated 4/4. Appropriations bill will trump RFA if discrepancies. Can the Council do a table to define conflicts between RFA and the Secretary s presentation? Then Council presents these items and requests clarification. Pressure of making commitment is really related to the need for LMEs to first decide how they are going to come together. This is huge. A number of LMEs already have a process and are working together but need time to finish this. 7/1 declaration is reasonable. Need answers to some of the questions (4/22) for LMEs to know how they want to come together. Looks like a graduated process (300,000 to 500,000) but isn t. This is a 1 time response. Will they hold harmless as LMEs merge? Not likely. Not hearing cuts in service dollars, but in administration only. HHS/DSS consolidation: How is this connecting with waiver or are they options? When the legislative big chairs laid out parameters they talked about administration, non profits, number

2 of area directed committee chairs to find savings and this is how they are doing it board consolidations. Ramon has responded to legislative questions on consolidated services The Secretary s proposal protects counties from financial overruns experienced by LMEs operating waivers. This is an important piece (i.e., they will monitor LMEs so closely that they will pull waiver if an LME is running wild with costs so it never gets to counties). Expect this to be in a bill, but not yet. Discussion of legislative activity and county commissioners ass n discussions of consolidation of human services groups in counties. Ramon is leading Wake Co. in this effort where there is consolidation. Business transaction restrictions: Conflicts if an LME staff is related to a provider staff. This is prohibited. Leza: discussed with DHHS, described how they would prevent that conflict and it was ok. Department wants to know about it and know how the LME will prevent conflicts. Do we run any risk by pushing date back? Opposition is working hard and any delay gives them time. Probably not. Riskier to stay with 5/20 date and allow opposition to say 6 weeks wasn t time for thoughtful process. What signatures are required for the RFA declaration? Also need to know fund balance and legislative cuts for LMEs to make informed decisions on declarations and mergers and moving forward. Budget may be out next Tuesday. Important issues but we need to be careful because the private vendors are saying they re ready and willing. Motion Debnam: Request that July 1 be the declaration date from May 20. 2nd: Hardy. Discussion: Plan on table from privates says they can do it. We need to be mindful of the potential negative result of anything we say. Request to extend over 6 weeks is reasonable and will demonstrate local process. This will be posed as a question. We don t need to take a formal vote and position on date. Motion withdrawn. Straw poll shows agreement to pose question to ask for extension to 7/1 for declaration. Another question: What are responsibilities and duties of non-waiver LMEs? 122c and RFI are unclear. Impacts the way lead and non-lead LMEs interact, boards, etc. Yvonne asked Mike to talk about new system design unrelated to RFA. Use of Mark Botts Waiver Communication: Yvonne shared Mark s response to the Council on risk and waivers. DHHS asked to see it. Is it ok for Council to share? Yes, has been shared with boards and others awhile ago. Yvonne will resend. Meeting with Benchmark: Yvonne gave a brief overview of her meeting with Benchmarks, which is the group that authored the streamlining bill. Council representatives will meet periodically with Benchmarks representatives. DMH & DMA Discussion Mike Watson s Comments Noted that he cannot answer questions on the RFA. He encouraged all to send questions in. After the 15 th, the Division will answer submitted questions as fast as possible. The Secretary s presentation is the vision for where we are and where we re going. Many managed care companies and providers are telling the General Assembly they can do the work at lower costs. This is our opportunity to have a publicly managed system with a local focus based on competencies and economies of scale. Savings associated are reasonable and relatively conservative. The Department and General Assembly want consistency and the PBH model. Have to deal with size issues: if you re under the required numbers, do something quickly. Single county issues: There will be options to do solo, create agreements. Encouraged single counties to come up with a model. Lots of concern from the DD community, much of it misguided/misrepresented. No indication that DD fares less well under this model. Steve and Beth are developing materials to counter DD concerns. Other issues: Budget cuts: Should know about these on Tuesday. Current target is $500M +. LMEs need to be able to articulate what cuts at that level will mean locally. Expect reductions/savings attributed to CCNCs. Legislation: A lot of things. Monitoring bill: DHHS position is that they re already looking at monitoring of providers thru Beth and PCG. Want a study bill and will look at duplication. Other bills around adult care homes. 1915i option: In process of looking at it. Totally focused on personal care services right now. Inconsistencies, overutilization, possible use of PCS in IMDs. Also ties with DOJ and

3 complaints. Will see 2 things: in-home PCS will phase out, with adult and child PCS coming in for in-home care. Will include assessment and increased requirements for ADLs. 1915(i) will be developed by February of next year and will have a single target population. The Division is very involved in this effort and keeping an eye on smaller programs. LMEs and CABHAs will get the issue of need to assess people in IMDs. DHHS is scrubbing that data to be sure they know who they re talking about. Rough data suggests adult care homes with people whose diagnosis would be IMDs. Will talk with LMEs about how to do this. About 3000 people. May have to furlough up to 5000 employees next week if federal issues aren t resolved next week. Medicaid will continue to flow, providers will get paid. State budget office is trying to manage this worst case scenario. Q: Are the rumors of Medicaid being handled as a block grant true? A: This scenario is being raised. Q: Any comments on consolidation of human services and how it relates to the waiver? LME consolidations spilling over to DSS and Health Depts? A: Under waiver looking for expertise, not sure if community consolidations move toward or away from that. Q: Any conflicts in Pathways with MCO needing to be autonomous? Could make that argument. Current governance model doesn t fit with waiver. Comments? Needs to be studied before moving everything out from under 122c. Broughton ground breaking has been delayed, but5 is still expected to move forward. Supports Intensity Scale (SIS) David Swann gave brief history on his call from DHHS regarding providing NPI numbers to SIS evaluators. Caller suggested that his LME needed to give its number to all providers. David brought this to MSWG to develop a consistent plan. What is the request to LMEs to share NPI numbers and what is the risk? We think there are implications for LMEs. In response to this question, Steve Jordan commented that he has no information on billing thru LMEs to conduct SIS evaluations. Flo Stein stated that the Division is trying to explore ways to move the system along. The call to David was simply intended to be exploratory. Service Expenditures Steve Jordan raised concerns regarding challenges to spending all dollars allocated and the risk to revert. Yvonne noted that the Council s Finance Officers Forum saw the following trend: providers are anxious, thus did not ramp back up after the $40M was reinstituted, and some of the larger CABHAs are laying off staff. All agreed that we need as much flexibility as possible. We need to get on the same page on service expenditures, want flexibility to spend these dollars at the local level to get support from the state to use dollars. Same is true for use of non-ucr dollars and limitations of use. We want the state to know of this dilemma and get support that LMEs can spend the dollars flexibly. We are asking the state to lift current requirements around single stream issues to shore up CABHAs and see this as aggregate expenditures of UCR and non-ucr. Steve Jordan wants a couple of people to meet next week with him and Bill Scott to come to a decision. CABHAs It was noted that when a CABHA expands an existing service into a new LME area, the CABHA is still required to contact the new LME and to execute an MOA with that LME. The LME can then conduct monitoring within 60 days. Council Work Group Reports & Discussion Advocacy Action Work Group David Swann noted the following: Tracking bills. The workgroup welcomes comments on them. They are updating the spreadsheet on bills and legislation. HB618: We need to state that we support the DHHS position to study the issue and base decisions on that. Strongly support study and believe that LMEs must be involved. Motion by Hennike. 2 nd by Swann. Voice vote unanimous. IVC bill: Brutal opposition and other groups want to be added. Yvonne is asking to meet with all involved on Tuesday to attempt a compromise. Will be heard by senate on Tuesday. House pulled it. We need to send letters of support. Will send reminder . HB423. Also get letters from hospitals and sheriffs. Clinical Services & Supports Work Group Met 3/24. Developed an LME survey on care coordination efforts, standardization, within waiver environment, Management Systems Work Group Discussion of state s plan for RFA. After Spring Policy Forum, there will be an information session on Community Care in Pennsylvania for anyone interested in learning about that.

4 Discussing CCNCs, their roles in the future of NC s activities; person centered health homes; provider monitoring; SIS; legacy LME functions. Regarding Waiver and Care Coordination Council will develop a paper articulating support for the waiver plan. This will include statement describing care management as a quality tool and as a justified activity for the waiver site. The Department determined that this will be part of the waiver. This care coordination function is similar to care coordination in BCBS. Looking at high utilizes and moving people to services to achieve best outcome using dollars available is industry model. It is also reflective of the CCNC model.

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62 H G E N E R A L ASSE M B L Y O F N O R T H C A R O L IN A SESSI O N 2011 H O USE DR H30269-L B-303A (03/24) D Short Title: Hospital Authority Territorial Jurisdiction. (Public) Sponsors: Referred to: Representative Torbett A BILL TO BE ENTITLED AN ACT TO DEFINE THE BOUNDARIES OF A HOSPITAL AUTHORITY AS THE TERRITORIAL BOUNDARIES OF THE CITY OR COUNTY CREATING THE AUTHORITY. The General Assembly of North Carolina enacts: SE C T I O N 1. G.S. 131E-20 reads as rewritten: " 131E-20. Boundaries of the authority. (a) The territorial boundaries of a hospital authority shall include the territorial boundaries of the city or county creating the authority and the area within 10 miles from the territorial boundaries of that city or county. authority. However, a hospital authority may engage in health care activities in a county outside its territorial boundaries pursuant to: (1) An agreement with a hospital facility if only one hospital currently exists in that county; (2) An agreement with any hospital if more than one hospital currently exists in that county; or (3) An agreement with any health care agency if no hospital currently exists in that county. Provided, however, that if a hospital authority enters into an agreement under subdivision (1), (2), or (3) of this subsection, the hospital authority shall first apply for and obtain a certificate of public advantage pursuant to G.S. 131E-192.1, et seq. (a1) In no event shall the territorial boundaries of a hospital authority include, in whole or in part, the area of any previously existing hospital authority. All priorities shall be determined on the basis of the time of issuance of the certificates of incorporation by the Secretary of State. (b) After the creation of an authority, the subsequent existence within its territorial boundaries of more than one city or county shall in no way affect the territorial boundaries of the authority." SE C T I O N 2. This act is effective when it becomes law. *DRH30269-LB-303A*

63 G E N E R A L ASSE M B L Y O F N O R T H C A R O L IN A SESSI O N 2011 H 1 H O USE BI L L 424* Short Title: Add'l Section 1915 Medicaid Waiver Sites. (Public) Sponsors: Referred to: Representatives Barnhart, Ingle, and Insko (Primary Sponsors). For a complete list of Sponsors, see Bill Information on the NCGA Web Site. Health and Human Services. March 23, A BILL TO BE ENTITLED AN ACT TO AUTHORIZE DHHS TO IMPLEMENT ADDITIONAL 1915(B)(C) MEDICAID WAIVER SITES AND THIRD-PARTY BILLING FOR STATE FACILITIES. The General Assembly of North Carolina enacts: SE C T I O N 1. Section of S.L is repealed. SE C T I O N 2. The Department of Health and Human Services shall implement additional capitated 1915(b)(c) Medicaid waivers during the fiscal year through a Request for Application (RFA) process for LME applicants who prove readiness. The waiver program shall include all Medicaid-covered mental health, developmental disabilities, and substance abuse services. Expansion of the waiver is contingent upon approval by the Centers for Medicare and Medicaid Services. SE C T I O N 3. G.S. 122C-55(g) reads as rewritten: "(g) Whenever there is reason to believe that the client is eligible for financial benefits through a governmental agency, a facility may disclose confidential information to State, local, or federal government agencies. Except as provided in G.S.122C-55(a3), subsections (a3) and (g1) of this section, disclosure is limited to that confidential information necessary to establish financial benefits for a client. After Except as provided in subsection (g1) of this section, after establishment of these benefits, the consent of the client or his legally responsible person is required for further release of confidential information under this subsection." SE C T I O N 4. G.S. 122C-55 is amended by adding a new subsection to read: "(g1) A facility may disclose confidential information for the purpose of collecting payment due the facility for the cost of care, treatment, or habilitation." SE C T I O N 5. This act is effective when it becomes law. *H424-v-1*

64 G E N E R A L ASSE M B L Y O F N O R T H C A R O L IN A SESSI O N 2011 H 1 H O USE BI L L 618* Short Title: Streamline Oversight/DHHS Service Providers. (Public) Sponsors: Referred to: Representatives Lewis and Hurley (Primary Sponsors). For a complete list of Sponsors, see Bill Information on the NCGA Web Site. Health and Human Services. April 6, A BILL TO BE ENTITLED AN ACT TO STREAMLINE DUPLICATE OVERSIGHT OF DHHS SERVICE PROVIDERS. The General Assembly of North Carolina enacts: SE C T I O N 1. Findings. Over the years, State and legislative actions intended to improve safety and quality of care have resulted in multiple, redundant reviews of Department of Health and Human Services (DHHS) service providers by various State and local agencies. This duplicative bureaucracy has led to wasted resources on the part of the monitoring agencies and the service provider, along with interrupted services to the consumer. SE C T I O N 2. The Secretary of Health and Human Services (hereinafter "the Secretary") shall establish a task force made up of division staff and providers to objectively compare the tools and checklists, currently in place, to look for redundancies and review items as to service provider monitoring that are not value added by August 1, The Secretary shall instruct this team to remove and streamline any duplication that is identified by December 31, SE C T I O N 3.(a) The Secretary of Health and Human Services shall create one regulatory body within the DHHS responsible for oversight review for service providers across all DHHS divisions to reduce duplication May 1, The Secretary shall instruct the new regulatory body to combine the multitude of reviews into a single annual review process. The creation of this regulatory body ensures objectivity in oversight and removes the conflict and undue influences upon decisions that may be prevalent in a local area. It also increases the likelihood of consistency in feedback and findings based on narrowing the variability around rule interpretation. The regulatory body shall aid in the reduction of excessive and unnecessary control over private enterprise. The regulatory body will include and comply with requirements of the national accrediting bodies for oversight management entities (NCQA, URAC) that pertain to provider agencies to avoid duplicative parallel reviews or monitoring of provider agencies by the oversight management entities. SE C T I O N 3.(b) The Secretary shall instruct the regulatory body to select a multidisciplinary team from staff and resources already in place from the various departments to allow for one streamlined annual review of service provider agencies by the team of the facility, compliance to rules, record assurances, clinical integrity, and staff training. The Secretary shall eliminate endorsement and all tools and checklists (ex. Provider Monitoring Tool-PMT and Frequency and Extent of Monitoring Tool-FEM) associated with Local Management Entity monitoring and oversight and replace with service licensure at an agency *H618-v-1*

65 General Assembly of North Carolina Session 2011 level, as opposed to a site-specific service license, that the multidisciplinary team issues. The multidisciplinary team may conduct additional reviews as indicated through Program Integrity flagged data, or a complaint or grievance. The annual review shall be agency specific not site-specific. The Secretary shall ensure that the multidisciplinary team includes specialized reviewers, with knowledge and experience specific to the services provided by the agency undergoing the annual review and rules applicable to those specific services and facilities. The Secretary will direct the multidisciplinary team to cross-walk the new annual review with the National Accreditation review to eliminate wasteful duplication. The Secretary shall direct the new regulatory body to create "core" multidisciplinary teams in locations across the state. For agencies with specialized services outside of the "core," the multidisciplinary team shall include specialized reviewers, with knowledge and experience specific to the services provided by the agency undergoing the annual review. When regular annual reviews are positive and meet compliance expectations for two consecutive years, the multidisciplinary team review shall be completed every two years pending any problems indicated through Program Integrity data, or a complaint or grievance. Such periodic review shall not necessarily require a return to annual monitoring for the service provider. The regulatory body shall have the power and authority to issue a request for corrective action, approve and monitor the corrective action, suspend and/or withdraw the billing process (contract, license, Medicaid enrollment for a specific service, etc.) for the service provider agency based on results from the annual or biennial review. The regulatory body shall have the discretion to determine whether infractions are site-specific or applicable to the agency as a whole. The regulatory body will be the central agency that responds to any complaints, abuse, neglect, and/or allegations. SE C T I O N 4. Chapter 143 of the General Statutes is amended by adding a new section to read: " 143B-139.6C. Coordination plan for the investigation of abuse or neglect complaints involving multiple agencies. For the purpose of avoiding duplication of effort and paperwork by service providers and the Department, to ensure a clear understanding and interpretation of compliance with applicable laws and rules, and to expedite the provision of effective services to clients, the Secretary of Health and Human Services shall direct the appropriate departmental divisions, in conjunction with providers and local oversight agencies, to establish a procedure for coordinating the investigation of complaints against licensed, certified, or accredited providers of services to recipients of social services or mental health, developmental disabilities, and substance abuse services through the regulatory body. When an abuse or neglect complaint is received by the Department and the complaint requires investigation by more than one division of the Department, the Secretary shall establish a coordination plan through the regulatory body to complete and share the results of the investigation with the appropriate bodies. The Secretary shall coordinate with the involved departmental divisions to review laws and rules that impact the investigation and to provide consistent and nonconflicting findings to the provider on what rules or laws have been violated and the corrections needed to comply with those laws and rules. The procedure shall provide for notice to service providers when a complaint is received. If a conflict arises among the departmental divisions concerning the interpretation of the law or rules, the conflict shall be resolved by the Secretary or, if necessary, by an amendment to rules or statutory clarification by the General Assembly. The provider shall not be deemed in violation of any rule, the interpretation of which is in conflict, until the conflict has been resolved and the provider informed of the decision." SE C T I O N 5.(a) The Secretary shall streamline the Medicaid enrollment process by directing the Division of Medical Assistance (DMA) to remove the requirement for annual reenrollment by September 1, Once a service provider is enrolled, the provider shall continue to maintain enrollment until the enrollment number has not been utilized for six Page 2 House Bill 618*-First Edition

66 General Assembly of North Carolina Session 2011 consecutive months. The six-month tracking process shall be instituted if it is not currently in place, eliminating duplicative and unnecessary paperwork. SE C T I O N 5.(b) The Secretary shall mandate that each DHHS division, agency, or department provide a fiscal note for every change or adjustment in service definition, policy, rule, or statute upon enactment. This requirement shall minimize the creation of unfunded mandates for provider agencies. SE C T I O N 5.(c) The Secretary shall direct the Division of Mental Health Developmental Disabilities, and Substance Abuse Services to allow for data sharing from the Incident Response Improvement System (IRIS) with service providers and the regulatory body by June 30, The system currently prohibits providers' access to their data for analysis, internal monitoring, quality improvement, and quality assurance reports for various entities. Because access for providers is restrictive, it creates a duplicative process requiring providers to repopulate the incident report data sets again into their own systems. SE C T I O N 5.(d) The Secretary shall establish a task force made up of division staff and providers to objectively evaluate the North Carolina Treatment Outcomes Program Performance System (NC-TOPPS) to improve the way data is accessible across services rather than site-specific to reflect valid comparisons of program outcomes by August 1, The system does not allow data to be captured which is population-specific thus limiting the depth of data comparison and outcome identification. SE C T I O N 5.(e) The Secretary shall allow private sector development and implementation of an Internet-based, secure, and consolidated data warehouse and archive for maintaining corporate, fiscal, and administrative records of providers by September 1, Use of the consolidated data warehouse is optional. Providers that choose to utilize the data warehouse shall ensure that the data is up to date and accessible to the regulatory body. A provider shall submit any revised, updated information to the data warehouse within 10 business days after receiving the request. The regulatory body that conducts administrative monitoring must use the data warehouse for document requests. If the information provided to the regulatory body is not current or is unavailable from the data warehouse and archive, the regulatory body may contact the provider directly. A provider that fails to comply with the regulatory body's requested documents may be subject to an on-site visit to ensure compliance. Access to the data warehouse must be provided without charge to the regulatory body under this section. SE C T I O N 6. The language in this act will be reviewed annually for compliance with updates to policy made by the following national accrediting bodies: Council on Accreditation (COA), CARF International, Council on Quality and Leadership (CQL), and the Joint Commission. SE C T I O N 7. This act is effective when it becomes law. House Bill 618*-First Edition Page 3